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Jericó D, Córdoba KM, Urigo F, Enríquez de Salamanca R, Anderson KE, Deybach JC, Ávila MA, Fontanellas A. Exploring current and emerging therapies for porphyrias. Liver Int 2024; 44:2174-2190. [PMID: 38813953 DOI: 10.1111/liv.15979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 05/31/2024]
Abstract
Porphyrias are rare, mostly inherited disorders resulting from altered activity of specific enzymes in the haem synthesis pathway that lead to accumulation of pathway intermediates. Photocutaneous symptoms occur when excess amounts of photoreactive porphyrins circulate in the blood to the skin, whereas increases in potentially neurotoxic porphyrin precursors are associated with neurovisceral symptoms. Current therapies are suboptimal and their mechanisms are not well established. As described here, emerging therapies address underlying disease mechanisms by introducing a gene, RNA or other specific molecule with the potential to cure or slow progression of the disease. Recent progress in nanotechnology and nanoscience, particularly regarding particle design and formulation, is expanding disease targets. More secure and efficient drug delivery systems have extended our toolbox for transferring specific molecules, especially into hepatocytes, and led to proof-of-concept studies in animal models. Repurposing existing drugs as molecular chaperones or haem synthesis inhibitors is also promising. This review summarizes key examples of these emerging therapeutic approaches and their application for hepatic and erythropoietic porphyrias.
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Affiliation(s)
- Daniel Jericó
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
| | - Karol M Córdoba
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
| | - Francesco Urigo
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
| | - Rafael Enríquez de Salamanca
- Department of Internal Medicine, Reference Center for Inherited Metabolic Disease-MetabERN, University Hospital 12 de Octubre, UCM, Madrid, Spain
| | - Karl E Anderson
- Porphyria Laboratory and Center, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Jean-Charles Deybach
- French Porphyria Reference Center (CRMR Porphyries France), Université Paris, Paris, France
| | - Matías A Ávila
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Antonio Fontanellas
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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2
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Balogun O, Nejak-Bowen K. Understanding Hepatic Porphyrias: Symptoms, Treatments, and Unmet Needs. Semin Liver Dis 2024; 44:209-225. [PMID: 38772406 PMCID: PMC11268267 DOI: 10.1055/s-0044-1787076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
Hepatic porphyrias are a group of metabolic disorders that are characterized by overproduction and accumulation of porphyrin precursors in the liver. These porphyrins cause neurologic symptoms as well as cutaneous photosensitivity, and in some cases patients can experience life-threatening acute neurovisceral attacks. This review describes the acute hepatic porphyrias in detail, including acute intermittent porphyria, hereditary coproporphyria, and variegate porphyria, as well as the hepatic porphyrias with cutaneous manifestations such as porphyria cutanea tarda and hepatoerythropoietic porphyria. Each section will cover disease prevalence, clinical manifestations, and current therapies, including strategies to manage symptoms. Finally, we review new and emerging treatment modalities, including gene therapy through use of adeno-associated vectors and chaperone therapies such as lipid nanoparticle and small interfering RNA-based therapeutics.
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Affiliation(s)
- Oluwashanu Balogun
- Department of Experimental Pathology, University of Pittsburgh, Pittsburgh, PA
| | - Kari Nejak-Bowen
- Department of Experimental Pathology, University of Pittsburgh, Pittsburgh, PA
- Pittsburgh Liver Institute, University of Pittsburgh, Pittsburgh, PA
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3
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Recent Insights into the Pathogenesis of Acute Porphyria Attacks and Increasing Hepatic PBGD as an Etiological Treatment. LIFE (BASEL, SWITZERLAND) 2022; 12:life12111858. [PMID: 36430993 PMCID: PMC9694773 DOI: 10.3390/life12111858] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/03/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022]
Abstract
Rare diseases, especially monogenic diseases, which usually affect a single target protein, have attracted growing interest in drug research by encouraging pharmaceutical companies to design and develop therapeutic products to be tested in the clinical arena. Acute intermittent porphyria (AIP) is one of these rare diseases. AIP is characterized by haploinsufficiency in the third enzyme of the heme biosynthesis pathway. Identification of the liver as the target organ and a detailed molecular characterization have enabled the development and approval of several therapies to manage this disease, such as glucose infusions, heme replenishment, and, more recently, an siRNA strategy that aims to down-regulate the key limiting enzyme of heme synthesis. Given the involvement of hepatic hemoproteins in essential metabolic functions, important questions regarding energy supply, antioxidant and detoxifying responses, and glucose homeostasis remain to be elucidated. This review reports recent insights into the pathogenesis of acute attacks and provides an update on emerging treatments aimed at increasing the activity of the deficient enzyme in the liver and restoring the physiological regulation of the pathway. While further studies are needed to optimize gene therapy vectors or large-scale production of liver-targeted PBGD proteins, effective protection of PBGD mRNA against the acute attacks has already been successfully confirmed in mice and large animals, and mRNA transfer technology is being tested in several clinical trials for metabolic diseases.
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4
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Longo M, Paolini E, Meroni M, Dongiovanni P. Cutting-Edge Therapies and Novel Strategies for Acute Intermittent Porphyria: Step-by-Step towards the Solution. Biomedicines 2022; 10:biomedicines10030648. [PMID: 35327450 PMCID: PMC8945550 DOI: 10.3390/biomedicines10030648] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/07/2022] [Accepted: 03/09/2022] [Indexed: 12/24/2022] Open
Abstract
Acute intermittent porphyria (AIP) is an autosomal dominant disease caused by the hepatic deficiency of porphobilinogen deaminase (PBGD) and the slowdown of heme biosynthesis. AIP symptomatology includes life-threatening, acute neurovisceral or neuropsychiatric attacks manifesting in response to precipitating factors. The latter promote the upregulation of 5-aminolevulinic acid synthase-1 (ALAS1), the first enzyme of heme biosynthesis, which promotes the overload of neurotoxic porphyrin precursors. Hemin or glucose infusions are the first-line therapies for the reduction of ALAS1 levels in patients with mild to severe AIP, while liver transplantation is the only curative treatment for refractory patients. Recently, the RNA-interference against ALAS1 was approved as a treatment for adult and adolescent patients with AIP. These emerging therapies aim to substitute dysfunctional PBGD with adeno-associated vectors for genome editing, human PBGD mRNA encapsulated in lipid nanoparticles, or PBGD protein linked to apolipoprotein A1. Finally, the impairment of glucose metabolism linked to insulin resistance, and mitochondrial aberrations during AIP pathophysiology provided new therapeutic targets. Therefore, the use of liver-targeted insulin and insulin-mimetics such as α-lipoic acid may be useful for overcoming metabolic dysfunction in these subjects. Herein, the present review aims to provide an overview of AIP pathophysiology and management, focusing on conventional and recent therapeutical approaches.
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Affiliation(s)
- Miriam Longo
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pad. Granelli, Via F Sforza 35, 20122 Milan, Italy; (M.L.); (E.P.); (M.M.)
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Erika Paolini
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pad. Granelli, Via F Sforza 35, 20122 Milan, Italy; (M.L.); (E.P.); (M.M.)
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, 20133 Milan, Italy
| | - Marica Meroni
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pad. Granelli, Via F Sforza 35, 20122 Milan, Italy; (M.L.); (E.P.); (M.M.)
| | - Paola Dongiovanni
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pad. Granelli, Via F Sforza 35, 20122 Milan, Italy; (M.L.); (E.P.); (M.M.)
- Correspondence: ; Tel.: +39-02-5503-3467; Fax: +39-02-5503-4229
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Córdoba KM, Serrano-Mendioroz I, Jericó D, Merino M, Jiang L, Sampedro A, Alegre M, Corrales F, Garrido MJ, Martini PGV, Lanciego JL, Prieto J, Berraondo P, Fontanellas A. Recombinant porphobilinogen deaminase targeted to the liver corrects enzymopenia in a mouse model of acute intermittent porphyria. Sci Transl Med 2022; 14:eabc0700. [PMID: 35020410 DOI: 10.1126/scitranslmed.abc0700] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Karol M Córdoba
- Hepatology Program, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.,Navarra Institute for Health Research (IDISNA), 31008 Pamplona, Spain
| | - Irantzu Serrano-Mendioroz
- Hepatology Program, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.,Navarra Institute for Health Research (IDISNA), 31008 Pamplona, Spain
| | - Daniel Jericó
- Hepatology Program, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.,Navarra Institute for Health Research (IDISNA), 31008 Pamplona, Spain
| | - María Merino
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Navarra, 31008 Pamplona, Spain
| | - Lei Jiang
- Moderna Inc., Cambridge, MA 02139, USA
| | - Ana Sampedro
- Hepatology Program, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.,Navarra Institute for Health Research (IDISNA), 31008 Pamplona, Spain
| | - Manuel Alegre
- Neurophysiology Laboratory, Neuroscience Area, CIMA and Clínica Universitaria, University of Navarra, 31008 Pamplona, Spain
| | - Fernando Corrales
- Proteomics Unit, Centro Nacional de Biotecnología (CSIC), 28049 Madrid, Spain
| | - María J Garrido
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Navarra, 31008 Pamplona, Spain
| | | | - José Luis Lanciego
- Navarra Institute for Health Research (IDISNA), 31008 Pamplona, Spain.,Neurosciences Department, CIMA-University of Navarra, 31008 Pamplona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNed), Instituto de Salud Carlos III, 28031 Madrid, Spain
| | - Jesús Prieto
- Hepatology Program, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain
| | - Pedro Berraondo
- Navarra Institute for Health Research (IDISNA), 31008 Pamplona, Spain.,Program of Immunology and Immunotherapy, Cima Universidad de Navarra, 31008 Pamplona, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Antonio Fontanellas
- Hepatology Program, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.,Navarra Institute for Health Research (IDISNA), 31008 Pamplona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
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6
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Jericó D, Córdoba KM, Jiang L, Schmitt C, Morán M, Sampedro A, Alegre M, Collantes M, Santamaría E, Alegre E, Culerier C, de Mendoza AEH, Oyarzabal J, Martín MA, Peñuelas I, Ávila MA, Gouya L, Martini PGV, Fontanellas A. mRNA-based therapy in a rabbit model of variegate porphyria offers new insights into the pathogenesis of acute attacks. MOLECULAR THERAPY. NUCLEIC ACIDS 2021; 25:207-219. [PMID: 34458006 PMCID: PMC8368795 DOI: 10.1016/j.omtn.2021.05.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 05/13/2021] [Indexed: 11/28/2022]
Abstract
Variegate porphyria (VP) results from haploinsufficiency of protoporphyrinogen oxidase (PPOX), the seventh enzyme in the heme synthesis pathway. There is no VP model that recapitulates the clinical manifestations of acute attacks. Combined administrations of 2-allyl-2-isopropylacetamide and rifampicin in rabbits halved hepatic PPOX activity, resulting in increased accumulation of a potentially neurotoxic heme precursor, lipid peroxidation, inflammation, and hepatocyte cytoplasmic stress. Rabbits also showed hypertension, motor impairment, reduced activity of critical mitochondrial hemoprotein functions, and altered glucose homeostasis. Hemin treatment only resulted in a slight drop in heme precursor accumulation but further increased hepatic heme catabolism, inflammation, and cytoplasmic stress. Hemin replenishment did protect against hypertension, but it failed to restore action potentials in the sciatic nerve or glucose homeostasis. Systemic porphobilinogen deaminase (PBGD) mRNA administration increased hepatic PBGD activity, the third enzyme of the pathway, and rapidly normalized serum and urine porphyrin precursor levels. All features studied were improved, including those related to critical hemoprotein functions. In conclusion, the VP model recapitulates the biochemical characteristics and some clinical manifestations associated with severe acute attacks in humans. Systemic PBGD mRNA provided successful protection against the acute attack, indicating that PBGD, and not PPOX, was the critical enzyme for hepatic heme synthesis in VP rabbits.
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Affiliation(s)
- Daniel Jericó
- Hepatology Program, Centre for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Karol M Córdoba
- Hepatology Program, Centre for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Lei Jiang
- Moderna Inc., Cambridge, MA 02139, USA
| | - Caroline Schmitt
- Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale U1149, 75018 Paris, France.,Centre Français des Porphyries, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes et Université de Paris, 92701 Colombes, France
| | - María Morán
- Mitochondrial Diseases Laboratory, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), U723, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Ana Sampedro
- Hepatology Program, Centre for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Manuel Alegre
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain.,Department of Clinical Neurophysiology, Clínica Universidad de Navarra (CUN), 31008 Pamplona, Spain
| | - María Collantes
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain.,MicroPET Research Unit, CIMA-CUN, 31008 Pamplona, Spain.,Nuclear Medicine Department, CUN, 31008 Pamplona, Spain
| | - Eva Santamaría
- Hepatology Program, Centre for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Estíbaliz Alegre
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain.,Department of Biochemistry, Service of Biochemistry, Clínica Universidad de Navarra (CUN), 31008 Pamplona, Spain
| | - Corinne Culerier
- Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale U1149, 75018 Paris, France.,Centre Français des Porphyries, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes et Université de Paris, 92701 Colombes, France
| | | | - Julen Oyarzabal
- Small Molecule Discovery Platform, Molecular Therapeutics Program, CIMA-University of Navarra, 31008 Pamplona, Spain
| | - Miguel A Martín
- Mitochondrial Diseases Laboratory, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), U723, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Iván Peñuelas
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain.,MicroPET Research Unit, CIMA-CUN, 31008 Pamplona, Spain.,Nuclear Medicine Department, CUN, 31008 Pamplona, Spain
| | - Matías A Ávila
- Hepatology Program, Centre for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Laurent Gouya
- Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale U1149, 75018 Paris, France.,Centre Français des Porphyries, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes et Université de Paris, 92701 Colombes, France
| | | | - Antonio Fontanellas
- Hepatology Program, Centre for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, 28029 Madrid, Spain
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7
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de Oliveira Neves AC, Galván I. Models for human porphyrias: Have animals in the wild been overlooked?: Some birds and mammals accumulate significant amounts of porphyrins in the body without showing the injurious symptoms observed in human porphyrias. Bioessays 2020; 42:e2000155. [PMID: 33155299 DOI: 10.1002/bies.202000155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/27/2020] [Indexed: 11/06/2022]
Abstract
Humans accumulate porphyrins in the body mostly during the course of porphyrias, diseases caused by defects in the enzymes of the heme biosynthesis pathway and that produce acute attacks, skin lesions and liver cancer. In contrast, some wild mammals and birds are adapted to accumulate porphyrins without injurious consequences. Here we propose viewing such physiological adaptations as potential solutions to human porphyrias, and suggest certain wild animals as models. Given the enzymatic activity and/or the patterns of porphyrin excretion and accumulation, the fox squirrel, the great bustard and the Eurasian eagle owl may constitute overlooked models for different porphyrias. The Harderian gland of rodents, where large amounts of porphyrins are synthesized, presents an underexplored potential for understanding the carcinogenic/toxic effect of porphyrin accumulation. Investigating how these animals avoid porphyrin pathogenicity may complement the use of laboratory models for porphyrias and provide new insights into the treatment of these disorders.
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Affiliation(s)
| | - Ismael Galván
- Department of Evolutionary Ecology, Doñana Biological Station, CSIC, Sevilla, 41092, Spain
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8
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Vera-Yunca D, Serrano-Mendioroz I, Sampedro A, Jericó D, Trocóniz IF, Fontanellas A, Parra-Guillén ZP. Computational disease model of phenobarbital-induced acute attacks in an acute intermittent porphyria mouse model. Mol Genet Metab 2019; 128:367-375. [PMID: 30639045 DOI: 10.1016/j.ymgme.2018.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/27/2018] [Accepted: 12/19/2018] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Acute intermittent porphyria (AIP) is characterized by hepatic over-production of the heme precursors when aminolevulinic acid (ALA)-synthase 1 is induced by endogenous or environmental factors. The aim of this study was to develop a semi-mechanistic computational model to characterize urine accumulation of heme precursors during acute attacks based on experimental pharmacodynamics data and support the development of new therapeutic strategies. METHODS Male AIP mice received recurrent phenobarbital challenge starting on days 1, 9, 16 and 30. 24-h urine excretion of ALA, porphobilinogen (PBG) and porphyrins from challenges D1, D9 and D30 constituted the training data set to build the mechanistic model using the population approach. In a second study, porphyrin and porphyrin precursor excretion from challenge D16 were used as a validation data set. RESULTS The computational model presented the following features: (i) urinary excretion of ALA, PBG and porphyrins was governed by unmeasured circulating heme precursor amounts, (ii) the circulating amounts of ALA and PBG were the precursors of circulating amounts of PBG and porphyrins, respectively, and (iii) the phenobarbital effect linearly increased the synthesis of circulating ALA and PBG levels. The model displayed good parameter precision (coefficient of variation below 32% in all parameters), and adequately described the experimental data. Finally, a theoretical hemin effect was implemented to illustrate the applicability of the model to dosage optimization in drug therapies. CONCLUSIONS A semi-mechanistic disease model was successfully developed to describe the temporal evolution of urinary heme precursor excretion during recurrent biochemical-induced acute attacks in AIP mice. This model represents the first computational approach to explore and optimize current and new therapies.
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Affiliation(s)
- Diego Vera-Yunca
- Pharmacometrics & Systems Pharmacology Research Unit, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | | | - Ana Sampedro
- Hepatology Program, Centre for Applied Medical Research, University of Navarra, Spain
| | - Daniel Jericó
- Hepatology Program, Centre for Applied Medical Research, University of Navarra, Spain
| | - Iñaki F Trocóniz
- Pharmacometrics & Systems Pharmacology Research Unit, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Antonio Fontanellas
- IdiSNA, Navarra Institute for Health Research, Pamplona, Spain; Hepatology Program, Centre for Applied Medical Research, University of Navarra, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Spain.
| | - Zinnia P Parra-Guillén
- Pharmacometrics & Systems Pharmacology Research Unit, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
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9
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Berraondo P, Martini PGV, Avila MA, Fontanellas A. Messenger RNA therapy for rare genetic metabolic diseases. Gut 2019; 68:1323-1330. [PMID: 30796097 DOI: 10.1136/gutjnl-2019-318269] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 02/04/2019] [Accepted: 02/05/2019] [Indexed: 12/12/2022]
Abstract
Decades of intense research in molecular biology and biochemistry are fructifying in the emergence of therapeutic messenger RNAs (mRNA) as a new class of drugs. Synthetic mRNAs can be sequence optimised to improve translatability into proteins, as well as chemically modified to reduce immunogenicity and increase chemical stability using naturally occurring uridine modifications. These structural improvements, together with the development of safe and efficient vehicles that preserve mRNA integrity in circulation and allow targeted intracellular delivery, have paved the way for mRNA-based therapeutics. Indeed, mRNAs formulated into biodegradable lipid nanoparticles are currently being tested in preclinical and clinical studies for multiple diseases including cancer immunotherapy and vaccination for infectious diseases. An emerging application of mRNAs is the supplementation of proteins that are not expressed or are not functional in a regulated and tissue-specific manner. This so-called 'protein replacement therapy' could represent a solution for genetic metabolic diseases currently lacking effective treatments. Here we summarise this new class of drugs and discuss the preclinical evidence supporting the potential of liver-mediated mRNA therapy for three rare genetic conditions: methylmalonic acidaemia, acute intermittent porphyria and ornithine transcarbamylase deficiency.
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Affiliation(s)
- Pedro Berraondo
- Immunology and Immunotherapy Program, Centro de Investigación Médica Aplicada (Cima), University of Navarra, Pamplona, Navarra, Spain.,Centro de Investigación Biomédica en Red de Cáncer, CIBERonc, Instituto de Salud Carlos III, Madrid, Spain.,Instituto de Investigación Sanitaria de Navarra IdiSNA, Pamplona, Spain
| | | | - Matias A Avila
- Instituto de Investigación Sanitaria de Navarra IdiSNA, Pamplona, Spain.,Hepatology Program, CIMA, University of Navarra, Pamplona, Navarra, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Antonio Fontanellas
- Instituto de Investigación Sanitaria de Navarra IdiSNA, Pamplona, Spain.,Hepatology Program, CIMA, University of Navarra, Pamplona, Navarra, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
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10
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Serrano-Mendioroz I, Sampedro A, Serna N, de Salamanca RE, Sanz-Parra A, Corrales F, Berraondo P, Millet O, Fontanellas A. Bioengineered PBGD variant improves the therapeutic index of gene therapy vectors for acute intermittent porphyria. Hum Mol Genet 2019; 27:3688-3696. [PMID: 30085095 DOI: 10.1093/hmg/ddy283] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 07/24/2018] [Indexed: 12/15/2022] Open
Abstract
A first-in-human gene therapy trial using a recombinant adeno-associated viral (rAAV) vector for acute intermittent porphyria (AIP) reveals that higher doses would be required to reach therapeutic levels of the porphobilinogen deaminase (PBGD) transgene. We developed a hyperfunctional PBGD protein to improve the therapeutic index without increasing vector dose. A consensus protein sequence from 12 mammal species was compared to the human PBGD sequence, and eight amino acids were selected. I291M and N340S variants showed the highest increase in enzymatic activity when expressed in prokaryotic and eukaryotic systems. In silico analysis indicates that isoleucine 291 to methionine and asparagine 340 to serine variants did not affect the active site of the enzyme. In vitro analysis indicated a synergistic interaction between these two substitutions that improve kinetic stability. Finally, full protection against a phenobarbital-induced attack was achieved in AIP mice after the administration of 1 × 1011 gc/kg of rAAV2/8-PBGD-I291M/N340S vector; three times lower than the dose required to achieve full protection with the control rAAV2/8-hPBGD vector. In conclusion, we have developed and characterized a hyperfunctional PBGD protein. The inclusion of this variant sequence in a rAAV2/8 vector allows the effective dose to be lowered in AIP mice.
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Affiliation(s)
- Irantzu Serrano-Mendioroz
- Hepatology Program, CIMA-University of Navarra, Spain.,Navarra Institute for Health Research (IDISNA), Pamplona, Spain
| | - Ana Sampedro
- Hepatology Program, CIMA-University of Navarra, Spain.,Navarra Institute for Health Research (IDISNA), Pamplona, Spain
| | - Naroa Serna
- Institut de Biotecnologia i de Biomedicina, Universitat Autònoma de Barcelona, Cerdanyola del Vallès 08193 Spain
| | | | - Arantza Sanz-Parra
- Protein Stability and Inherited Disease Laboratory, CIC bioGUNE, Derio, Spain
| | - Fernando Corrales
- Proteomics Unit, Centro Nacional de Biotecnología (CSIC), Madrid, Spain
| | - Pedro Berraondo
- Navarra Institute for Health Research (IDISNA), Pamplona, Spain.,Program of Immunology and Immunotherapy, CIMA-University of Navarra, Pamplona, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Spain
| | - Oscar Millet
- Protein Stability and Inherited Disease Laboratory, CIC bioGUNE, Derio, Spain
| | - Antonio Fontanellas
- Hepatology Program, CIMA-University of Navarra, Spain.,Navarra Institute for Health Research (IDISNA), Pamplona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
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11
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Serrano-Mendioroz I, Sampedro A, Alegre M, Enríquez de Salamanca R, Berraondo P, Fontanellas A. An Inducible Promoter Responsive to Different Porphyrinogenic Stimuli Improves Gene Therapy Vectors for Acute Intermittent Porphyria. Hum Gene Ther 2018; 29:480-491. [PMID: 28990424 DOI: 10.1089/hum.2017.056] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Porphobilinogen deaminase (PBGD) gene therapy represents a promising therapeutic option for acute intermittent porphyria (AIP) patients suffering recurrent acute attacks. A first-in-human Phase I clinical trial confirmed the safety and tolerability of adeno-associated virus (AAV)-AAT-PBGD gene therapy, but higher doses and/or more efficient vectors are needed to achieve therapeutic expression of the transgene. This study assayed the insertion into the promoter of a short enhancer element able to induce transgene expression during exposure to endogenous and exogenous stimuli related to the pathology of the disease. The inclusion in tandem of two elements of the minimal functional sequence of human δ-aminolevulinic acid synthase drug-responsive enhancing sequence (ADRES) positioned upstream of the promoter strongly induced transgene expression in the presence of estrogens, starvation, and certain drugs known to trigger attacks in porphyria patients. The inclusion of two ADRES motives in an AAV vector improved therapeutic efficacy, reducing 10-fold the effective dose in AIP mice. In conclusion, the inclusion of specific enhancer elements in the promoter of gene therapy vectors for AIP was able to overexpress the therapeutic transgene when it is most needed, at the time when porphyrinogenic factors increase the demand for hepatic heme and precipitate acute porphyria attacks.
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Affiliation(s)
| | - Ana Sampedro
- 1 Hepatology Program, Centre for Applied Medical Research, University of Navarra, Pamplona, Spain
| | - Manuel Alegre
- 2 Neurophysiology Laboratory, Neuroscience Area, Centre for Applied Medical Research and University Clinic of Navarra, Pamplona, Spain
| | | | - Pedro Berraondo
- 4 Program of Immunology and Immunotherapy, Centre for Applied Medical Research, University of Navarra, Pamplona, Spain .,5 Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain .,6 Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Spain
| | - Antonio Fontanellas
- 1 Hepatology Program, Centre for Applied Medical Research, University of Navarra, Pamplona, Spain .,5 Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain .,7 CIBEREHD. University Clinic Navarra , Instituto de Salud Carlos III, Pamplona, Spain
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12
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Abstract
Acute intermittent porphyria (AIP) is an autosomal dominant metabolic disease caused by hepatic deficiency of hydroxymethylbilane synthase (HMBS), the third enzyme of the heme synthesis pathway. The dominant clinical feature is acute neurovisceral attack associated with high production of potentially neurotoxic porphyrin precursors due to increased hepatic heme consumption. Current Standard of Care is based on a down-regulation of hepatic heme synthesis using heme therapy. Recurrent hyper-activation of the hepatic heme synthesis pathway affects about 5% of patients and can be associated with neurological and metabolic manifestations and long-term complications including chronic kidney disease and increased risk of hepatocellular carcinoma. Prophylactic heme infusion is an effective strategy in some of these patients, but it induces tolerance and its frequent application may be associated with thromboembolic disease and hepatic siderosis. Orthotopic liver transplantation is the only curative treatment in patients with recurrent acute attacks. Emerging therapies including replacement enzyme therapy or gene therapies (HMBS-gene transfer and ALAS1-gene expression inhibition) are being developed to improve quality of life, reduce the significant morbidity associated with current therapies and prevent late complications such as hepatocellular cancer or kidney failure in HMBS mutation carriers with long-standing high production of noxious heme precursors. Herein, we provide a critical digest of the recent literature on the topic and a summary of recently developed approaches to AIP treatment and their clinical implications.
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13
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D’Avola D, Gonzalez Aseguinolaza G. Prospect and progress of gene therapy in acute intermittent porphyria. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1191346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Delia D’Avola
- Liver Unit, CIBERehd, and IDISNAt, Clinica Universidad Navarra, Pamplona, Spain
| | - Gloria Gonzalez Aseguinolaza
- Foundation for Applied Medical Research, Gene Therapy and Regulation of Gene Expression, CIMA, and IDISNA, Navarra, Spain
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14
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Yin Z, Wahlin S, Ellis ECS, Harper P, Ericzon BG, Nowak G. Hepatocyte Transplantation Ameliorates the Metabolic Abnormality in a Mouse Model of Acute Intermittent Porphyria. Cell Transplant 2014; 23:1153-62. [DOI: 10.3727/096368913x666980] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Acute intermittent porphyria (AIP) is an autosomal dominant disorder characterized by insufficient porphobilinogen deaminase (PBGD) activity. When hepatic heme synthesis is induced, porphobilinogen (PBG) and 5-aminolevulinic acid (ALA) accumulate, which causes clinical symptoms such as abdominal pain, neuropathy, and psychiatric disturbances. Our aim was to investigate if hepatocyte transplantation can prevent or minimize the metabolic alterations in an AIP mouse model. We transplanted wild-type hepatocytes into PBGD-deficient mice and induced heme synthesis with phenobarbital. ALA and PBG concentrations in plasma were monitored, and the gene transcriptions of hepatic enzymes ALAS1, PBGD, and CYP2A5 were analyzed. Results were compared with controls and correlated to the percentage of engrafted hepatocytes. The accumulation of ALA and PBG was reduced by approximately 50% after the second hepatocyte transplantation. We detected no difference in mRNA levels of PBGD, ALAS1, or CYP2A5. Engraftment corresponding to 2.7% of the total hepatocyte mass was achieved following two hepatocyte transplantations. A lack of precursor production in less than 3% of the hepatocytes resulted in a 50% reduction in plasma precursor concentrations. This disproportional finding suggests that ALA and PBG produced in PBGD-deficient hepatocytes crossed cellular membranes and was metabolized by transplanted cells. The lack of effect on enzyme mRNA levels suggests that no significant efflux of heme from normal to PBGD-deficient hepatocytes takes place. Further studies are needed to establish the minimal number of engrafted hepatocytes needed to completely correct the metabolic abnormality in AIP and whether amelioration of the metabolic defect by partial restoration of PBGD enzyme activity translates into a clinical effect in human AIP.
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Affiliation(s)
- Zhaohui Yin
- Division of Transplantation Surgery, Department for Clinical Science, Intervention and Technology CLINTEC, Karolinska University Hospital, Stockholm, Sweden
- Department of General Surgery, First Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
| | - Staffan Wahlin
- Department of Gastroenterology and Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ewa C. S. Ellis
- Division of Transplantation Surgery, Department for Clinical Science, Intervention and Technology CLINTEC, Karolinska University Hospital, Stockholm, Sweden
| | - Pauline Harper
- Porphyria Centre Sweden, Division of Metabolic Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Bo-Göran Ericzon
- Division of Transplantation Surgery, Department for Clinical Science, Intervention and Technology CLINTEC, Karolinska University Hospital, Stockholm, Sweden
| | - Greg Nowak
- Division of Transplantation Surgery, Department for Clinical Science, Intervention and Technology CLINTEC, Karolinska University Hospital, Stockholm, Sweden
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15
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Augmenting PBGD Expression in the Liver as a Novel Gene Therapy for Acute Intermittent Porphyria (AIPgene). HUM GENE THER CL DEV 2014; 25:61-3. [DOI: 10.1089/humc.2014.2506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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16
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Harding CO. Seeking a cure for the royal pain. Hum Gene Ther 2013; 24:968-9. [PMID: 24329139 DOI: 10.1089/hum.2013.2522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Cary O Harding
- Departments of Molecular and Medical Genetics, and Pediatrics, Oregon Health & Science University , Portland, OR 97239
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17
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Pañeda A, Lopez-Franco E, Kaeppel C, Unzu C, Gil-Royo AG, D'Avola D, Beattie SG, Olagüe C, Ferrero R, Sampedro A, Mauleon I, Hermening S, Salmon F, Benito A, Gavira JJ, Cornet ME, del Mar Municio M, von Kalle C, Petry H, Prieto J, Schmidt M, Fontanellas A, González-Aseguinolaza G. Safety and Liver Transduction Efficacy of rAAV5-cohPBGD in Nonhuman Primates: A Potential Therapy for Acute Intermittent Porphyria. Hum Gene Ther 2013; 24:1007-17. [DOI: 10.1089/hum.2013.166] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- Astrid Pañeda
- Division of Hepatology and Gene Therapy, Center for Applied Medical Research, 31008 Pamplona, Spain
- DIGNA Biotech, 28020 Madrid, Spain
| | - Esperanza Lopez-Franco
- Division of Hepatology and Gene Therapy, Center for Applied Medical Research, 31008 Pamplona, Spain
| | - Christine Kaeppel
- National Center for Tumor Diseases and German Cancer Research Center, 69120 Heidelberg, Germany
| | - Carmen Unzu
- Division of Hepatology and Gene Therapy, Center for Applied Medical Research, 31008 Pamplona, Spain
| | - Ana Gloria Gil-Royo
- Department of Pharmacology and Toxicology, University of Navarra, (UNAV), 31008 Pamplona, Spain
| | - Delia D'Avola
- Department of Radiology, Department of Cardiology, University Clinic, UNAV, 31008 Pamplona, Spain
- Liver Unit and CIBERehd, 31008 Pamplona, Spain
| | | | - Cristina Olagüe
- Division of Hepatology and Gene Therapy, Center for Applied Medical Research, 31008 Pamplona, Spain
| | - Roberto Ferrero
- Division of Hepatology and Gene Therapy, Center for Applied Medical Research, 31008 Pamplona, Spain
| | - Ana Sampedro
- Division of Hepatology and Gene Therapy, Center for Applied Medical Research, 31008 Pamplona, Spain
| | - Itsaso Mauleon
- Division of Hepatology and Gene Therapy, Center for Applied Medical Research, 31008 Pamplona, Spain
| | | | | | - Alberto Benito
- Department of Radiology, Department of Cardiology, University Clinic, UNAV, 31008 Pamplona, Spain
| | - Juan Jose Gavira
- Department of Radiology, Department of Cardiology, University Clinic, UNAV, 31008 Pamplona, Spain
| | | | | | - Christof von Kalle
- National Center for Tumor Diseases and German Cancer Research Center, 69120 Heidelberg, Germany
| | | | - Jesus Prieto
- Division of Hepatology and Gene Therapy, Center for Applied Medical Research, 31008 Pamplona, Spain
- Department of Radiology, Department of Cardiology, University Clinic, UNAV, 31008 Pamplona, Spain
- Liver Unit and CIBERehd, 31008 Pamplona, Spain
| | - Manfred Schmidt
- National Center for Tumor Diseases and German Cancer Research Center, 69120 Heidelberg, Germany
| | - Antonio Fontanellas
- Division of Hepatology and Gene Therapy, Center for Applied Medical Research, 31008 Pamplona, Spain
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18
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Unzu C, Sampedro A, Mauleón I, González-Aparicio M, Enríquez de Salamanca R, Prieto J, Aragón T, Fontanellas A. Helper-dependent adenoviral liver gene therapy protects against induced attacks and corrects protein folding stress in acute intermittent porphyria mice. Hum Mol Genet 2013; 22:2929-40. [DOI: 10.1093/hmg/ddt148] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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19
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Abstract
Porphyric neuropathy often poses a diagnostic dilemma; it is typically associated with the hepatic porphyrias, characterized by acute life-threatening attacks of neurovisceral symptoms that mimic a range of acute medical and psychiatric conditions. The development of acute neurovisceral attacks is responsive to environmental factors, including drugs, hormones, and diet. This chapter reviews the clinical manifestations, genetics, pathophysiology, and mechanisms of neurotoxicity of the acute hepatic porphyrias. While the etiology of the neurological manifestations in the acute porphyrias remains undefined, the main hypotheses include toxicity of porphyrin precursors and deficiency of heme synthesis. These hypotheses will be discussed with reference to novel experimental models of porphyric neuropathy.
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Affiliation(s)
- Cindy Shin-Yi Lin
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia.
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20
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Hift RJ, Thunell S, Brun A. Drugs in porphyria: From observation to a modern algorithm-based system for the prediction of porphyrogenicity. Pharmacol Ther 2011; 132:158-69. [DOI: 10.1016/j.pharmthera.2011.06.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 06/01/2011] [Indexed: 02/06/2023]
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21
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Lin CSY, Lee MJ, Park SB, Kiernan MC. Purple pigments: the pathophysiology of acute porphyric neuropathy. Clin Neurophysiol 2011; 122:2336-44. [PMID: 21855406 DOI: 10.1016/j.clinph.2011.07.036] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 07/07/2011] [Accepted: 07/08/2011] [Indexed: 10/15/2022]
Abstract
The porphyrias are inherited metabolic disorders arising from disturbance in the haem biosynthesis pathway. The neuropathy associated with acute intermittent porphyria (AIP) occurs due to mutation involving the enzyme porphobilinogen deaminase (PBGD) and is characterised by motor-predominant features. Definitive diagnosis often encompasses a combination of biochemical, enzyme analysis and genetic testing, with clinical neurophysiological findings of a predominantly motor axonal neuropathy. Symptomatic and supportive treatment are the mainstays during an acute attack. If administered early, intravenous haemin may prevent progression of neuropathy. While the pathophysiology of AIP neuropathy remains unclear, axonal dysfunction appears intrinsically linked to the effects of neural energy deficits acquired through haem deficiency coupled to the neurotoxic effects of porphyrin precursors. The present review will provide an overview of AIP neuropathy, including discussion of recent advances in understanding developed through neurophysiological approaches that have further delineated the pathophysiology of axonal degeneration.
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Affiliation(s)
- Cindy S-Y Lin
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia.
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22
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Siegesmund M, van Tuyll van Serooskerken AM, Poblete-Gutiérrez P, Frank J. The acute hepatic porphyrias: current status and future challenges. Best Pract Res Clin Gastroenterol 2010; 24:593-605. [PMID: 20955962 DOI: 10.1016/j.bpg.2010.08.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Revised: 08/26/2010] [Accepted: 08/28/2010] [Indexed: 01/31/2023]
Abstract
The porphyrias are predominantly inherited metabolic disorders, which result from a specific deficiency of one of the eight enzymes along the pathway of haem biosynthesis. Historically, they have been classified into hepatic and erythropoietic forms, based on the primary site of expression of the prevailing dysfunctional enzyme. From a clinical point of view, however, it is more convenient to subdivide them into acute and non-acute porphyrias, thereby primarily considering the potential occurrence of life-threatening acute neurovisceral attacks. Unrecognised or untreated, such an acute porphyric attack is associated with a significant mortality of up to 10%. The acute hepatic porphyrias comprise acute intermittent porphyria, variegate porphyria, hereditary coproporphyria, and δ-aminolevulinic acid dehydratase deficiency porphyria. Making a precise diagnosis may be difficult because the different types of porphyrias may show overlapping clinical and biochemical characteristics. To date, the therapeutic possibilities are limited and mainly symptomatic. In this overview we report on what is currently known about pathogenesis, clinic, diagnostics, and therapy of the acute hepatic porphyrias. We further point out actual and future challenges in the management of these diseases.
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Affiliation(s)
- Marko Siegesmund
- Department of Dermatology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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23
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Unzu C, Sampedro A, Mauleón I, Alegre M, Beattie SG, de Salamanca RE, Snapper J, Twisk J, Petry H, González-Aseguinolaza G, Artieda J, Rodríguez-Pena MS, Prieto J, Fontanellas A. Sustained enzymatic correction by rAAV-mediated liver gene therapy protects against induced motor neuropathy in acute porphyria mice. Mol Ther 2010; 19:243-50. [PMID: 20877347 DOI: 10.1038/mt.2010.210] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Acute intermittent porphyria (AIP) is characterized by a hereditary deficiency of hepatic porphobilinogen deaminase (PBGD) activity. Clinical features are acute neurovisceral attacks accompanied by overproduction of porphyrin precursors in the liver. Recurrent life-threatening attacks can be cured only by liver transplantation. We developed recombinant adeno-associated virus (rAAV) vectors expressing human PBGD protein driven by a liver-specific promoter to provide sustained protection against induced attacks in a predictive model for AIP. Phenobarbital injections in AIP mice induced porphyrin precursor accumulation, functional block of nerve conduction, and progressive loss of large-caliber axons in the sciatic nerve. Hepatocyte transduction showed no gender variation after rAAV2/8 injection, while rAAV2/5 showed lower transduction efficiency in females than males. Full protection against induced phenobarbital-attacks was achieved in animals showing over 10% of hepatocytes expressing high amounts of PBGD. More importantly, sustained hepatic expression of hPBGD protected against loss of large-caliber axons in the sciatic nerve and disturbances in nerve conduction velocity as induced by recurrent phenobarbital administrations. These data show for the first time that porphyrin precursors generated in the liver interfere with motor function. rAAV2/5-hPBGD vector can be produced in sufficient quantity for an intended gene therapy trial in patients with recurrent life-threatening porphyria attacks.
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Affiliation(s)
- Carmen Unzu
- Gene Therapy and Hepatology Area, Centre for Applied Medical Research, University of Navarra, Pamplona, Spain
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24
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Intensive pharmacological immunosuppression allows for repetitive liver gene transfer with recombinant adenovirus in nonhuman primates. Mol Ther 2010; 18:754-65. [PMID: 20087317 DOI: 10.1038/mt.2009.312] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Repeated administration of gene therapies is hampered by host immunity toward vectors and transgenes. Attempts to circumvent antivector immunity include pharmacological immunosuppression or alternating different vectors and vector serotypes with the same transgene. Our studies show that B-cell depletion with anti-CD20 monoclonal antibody and concomitant T-cell inhibition with clinically available drugs permits repeated liver gene transfer to a limited number of nonhuman primates with recombinant adenovirus. Adenoviral vector-mediated transfer of the herpes simplex virus type 1 thymidine kinase (HSV1-tk) reporter gene was visualized in vivo with a semiquantitative transgene-specific positron emission tomography (PET) technique, liver immunohistochemistry, and immunoblot for the reporter transgene in needle biopsies. Neutralizing antibody and T cell-mediated responses toward the viral capsids were sequentially monitored and found to be repressed by the drug combinations tested. Repeated liver transfer of the HSV1-tk reporter gene with the same recombinant adenoviral vector was achieved in macaques undergoing a clinically feasible immunosuppressive treatment that ablated humoral and cellular immune responses. This strategy allows measurable gene retransfer to the liver as late as 15 months following the first adenoviral exposure in a macaque, which has undergone a total of four treatments with the same adenoviral vector.
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25
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Clavero S, Bishop DF, Haskins ME, Giger U, Kauppinen R, Desnick RJ. Feline acute intermittent porphyria: a phenocopy masquerading as an erythropoietic porphyria due to dominant and recessive hydroxymethylbilane synthase mutations. Hum Mol Genet 2009; 19:584-96. [PMID: 19934113 DOI: 10.1093/hmg/ddp525] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Human acute intermittent porphyria (AIP), the most common acute hepatic porphyria, is an autosomal dominant inborn error of heme biosynthesis due to the half-normal activity of hydroxymethylbilane synthase (HMB-synthase). Here, we describe the first naturally occurring animal model of AIP in four unrelated cat lines who presented phenotypically as congenital erythropoietic porphyria (CEP). Affected cats had erythrodontia, brownish urine, fluorescent bones, and markedly elevated urinary uroporphyrin (URO) and coproporphyrin (COPRO) consistent with CEP. However, their uroporphyrinogen-III-synthase (URO-synthase) activities (deficient in CEP) were normal. Notably, affected cats had half-normal HMB-synthase activities and elevated urinary 5-aminolevulinic acid (ALA) and porphobilinogen (PBG), the deficient enzyme and accumulated metabolites in human AIP. Sequencing the feline HMB-synthase gene revealed different mutations in each line: a duplication (c.189dupT), an in-frame 3 bp deletion (c.842_844delGAG) identical to that causing human AIP and two missense mutations, c.250G>A (p.A84T) and c.445C>T (p.R149W). Prokaryotic expression of mutations c.842_844delGAG and c.445C>T resulted in mutant enzymes with <1% wild-type activity, whereas c.250G>A expressed a stable enzyme with approximately 35% of wild-type activity. The discolored teeth from the affected cats contained markedly elevated URO I and III, accounting for the CEP-like phenocopy. In three lines, the phenotype was an autosomal dominant trait, while affected cats with the c.250G>A (p.A84T) mutation were homozygous, a unique recessive form of AIP. These animal models may permit further investigation of the pathogenesis of the acute, life-threatening neurological attacks in human AIP and the evaluation of therapeutic strategies. GenBank Accession Numbers: GQ850461-GQ850464.
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Affiliation(s)
- Sonia Clavero
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY 10029-6574, USA
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